Resisting unchecked pragmatism in global health
Authors: James Smith, Ezekiel Boro, Edwin Jit Leung Kwong, Megan Schmidt-Sane
Journal: The Lancet Global Health (2023)

The Lancet Global Health March 2023 Editorial takes a bleak view of some of the most harmful expressions of power and politics that undermine the realisation of global health: coloniality, biomedicalisation, depoliticisation, extractivism, and self-interest.1The Lancet Global HealthPragmatic global health.Lancet Glob Health. 2023; 11: e301Summary Full Text Full Text PDF PubMed Google Scholar These expressions of power are so interwoven into the history and contemporary practice of global health that it has been suggested it might not be possible to achieve a decolonised global health,2Hirsch LA Is it possible to decolonise global health institutions?.Lancet. 2021; 397: 189-190Summary Full Text Full Text PDF PubMed Scopus (36) Google Scholar or that with effective anti-colonial action global health might altogether cease to exist.3Abimbola S Pai M Will global health survive its decolonisation?.Lancet. 2020; 396: 1627-1628Summary Full Text Full Text PDF PubMed Scopus (120) Google Scholar Against this backdrop, the emphasis on pragmatic global health as articulated in the same editorial falls short of the requisite principled positioning and subsequent radical action needed to counteract the forces that compromise the discipline. To problematise pragmatism, two important distinctions should be made in its conceptualisation: pragmatism as an epistemological paradigm, and pragmatism as an approach to change. Pragmatism as an epistemological paradigm has value in its defence of the pluriversality and contextualisation of knowledge. This approach values positioning and theorising on the basis of its practical consequences, which should in turn encourage the localisation and contextualisation of pathways for knowledge production to practice. However, this approach also raises several important questions. Who determines the "usability of evidence in practice"1The Lancet Global HealthPragmatic global health.Lancet Glob Health. 2023; 11: e301Summary Full Text Full Text PDF PubMed Google Scholar and against what criteria? What value do global health policy makers and practitioners ascribe to knowledge that does not appear to have an immediate, practical application? A narrow interpretation of usability has long privileged the pursuit of seemingly simple technical interventions, and remains one of the greatest barriers to concerted engagement with complex systems and the political and economic root causes of ill-health. Bridging the know–do gap necessarily requires radically different ways of both knowing and doing that look beyond evidence-based biomedical paradigms, and closer to what Seye Abimbola4Abimbola S When dignity meets evidence.Lancet. 2023; 401: 340-341Summary Full Text Full Text PDF Google Scholar describes as dignity-based practice. Pragmatism as an approach to political and social change describes a commitment to incrementalism and compromise in pursuit of what is feasible or satisfactory at a given moment. Pragmatists are often perceived as action orientated, and idealists as naive dreamers. On the contrary, idealists clearly also strive for action and change, and visionaries, dreamers, and radical voices should not be dismissed so readily on this basis. Of greater concern is the proximity between the determination of usability and an assessment of what can be realistically and practically achieved under current circumstances. What limitations do we place on our collective imagination when we adopt such an approach? Relatedly, consequentialism as the philosophical foundation of pragmatism broadly neglects questions of motivation, process, and aspiration: what drives us, how do we get to where we want to go, and what world do we ultimately want to inhabit? We argue that a singular focus on either values and good intentions (ie, deontological global health) or anticipated and measured impacts (ie, consequentialist global health) will never suffice. One ethical position should continually unsettle the other. The promotion of pragmatism alone will be the death of global health, if it has not killed it already. Currently, pragmatism in global health is pervasive and unchecked, which enables conservative positioning and reformist, incremental change processes that typically serve to preserve the status quo. This pragmatism enables situations such as those in which influential ethicists call for the roll-out of more harmful treatments in low-income and middle-income countries because such treatments are cheaper than safer alternatives.5Persad GC Emanuel E J The ethics of expanding access to cheaper, less effective treatments.Lancet. 2016; 388: 932-934Summary Full Text Full Text PDF PubMed Scopus (19) Google Scholar A pragmatist might see value in this position, insofar as coverage of some form of treatment increases, and yet no systemic change ultimately occurs: the status quo is effectively maintained and injustice and inequity are further embedded into the architecture of global health. Such positioning represents yet another example of the failure of imagination that has stymied the potential of global health; pragmatists tend to see the world as it currently is, and not as it has the potential to be. Of note, several of the urgently necessary changes raised in The Lancet Global Health Editorial1The Lancet Global HealthPragmatic global health.Lancet Glob Health. 2023; 11: e301Summary Full Text Full Text PDF PubMed Google Scholar (eg, respecting people as agentive; emphasising locally-driven and participatory action; and embracing a pluriversality of approaches, experiences and forms of knowledge) are enablers of epistemological pragmatism, but are shaped foremost by a steadfast commitment to principles and ideals: respect, solidarity, and the pursuit of equity and justice. What this muddling of the pragmatic and the idealistic underscores is that no single approach will allow us to dismantle systems of power that undermine the realisation of global health. Driven by the concerns and priorities of people most affected by the failures of global health, reformists and revolutionaries, and pragmatists and idealists, all have a role in imagining that another world is possible, and pushing together until we get there. We declare no competing interests. JS thanks John Pringle for his insightful reflections during the conceptualisation of this manuscript. Pragmatic global healthGlobal health as a knowledge system remains marred by (neo)colonialism , which instils and maintains worrisome asymmetries of power. Moreover, global health solutions all too often fall foul of over medicalisation : the tendency to focus exclusively on biomedical solutions to control individual risk factors without tackling deep-rooted social determinants of health through political and social actions. The co-existence of colonialism and overmedicalisation has enabled parachute (or helicopter) research and a persistent gap between knowledge and practice, as the real-world usability of the evidence produced is seldom the primary focus in this research paradigm. Full-Text PDF Open Access